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Miscellaneous - 205 BARKER STREET 4/30/2018
cc Imms row- rn I FIN 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of.ongoing construction activity, and maybe_deemed_bythe.Inspector_of_Wires abandoned_and_invalid-if he—.. _ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or -the installing entity stated on the permit application. El The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of T the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any pemut or approval that was { "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending"through August 15, 2012. [Rule 8—Permit/Date Closed Z.Q _ / *°k* Note: Reapply for new permi 0 Permit Extension Act — Permit/Date Closed: Date 1. -D 2 N z. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .. ..L., .+-b-P-�ecj. has permission to perform ..}.� . (� .I.F. ki:-- . 1-,, . W. , 6 J p wiring in the building of n p�,�-�.;,�.............. . at .......'l'...�?.�s-?c' S.... ,North Andover, ass. Fee?-, .. Lic. No. ELECTRICAL INSPE Check # 1:7 Gi I I it 11037 t� Commonwealth of Massachusetts Department of Fire Services , BOARD OF FIRE PREVENTION REGULATIONS J It Official Use Only Permit No. 1 / n- 7 -occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 414 Z l 00 City or Town of: NORTH ANDOVER To the Ins ctor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes J4 Purpose of Building 2'S ��e ✓`L-� - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters ' Location and Nature of Proposed Electrical Work: 774, ua e-- � ASrt--� Sv �� Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ElIn- ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS [No. of Zones No. of Switches �r lO No. of Gas Burgers No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis osers p Heat Pumpum Totals: Nber Tons J.KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW SecNo. uritof De ides or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. H dromassa a Bathtubs Y g No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of E ectrical Work: �ffir (When required by municipal policy.) Work to Start: '� f Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CORAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covera orce, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and penalties of perjury, that the in o Itis appli ion is true and complete. FIRM NAME:. 1, 1� LTI� l� LIC. NO.: ` Licensee: V ,j "j �-pr 0 Signature (If applicable, enter "xempt" in the license number line. ( Bus. Tel. No.:97)1 `302-`? / Address: 10 Et36'�, _ , (oUM z t� _ Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. J i ... •.fl.1UJL•/YJ'V��y�-{�-./`,•.yJ1.L�-LI�J�-yL�JL.pyJ. �.��®Qy��@yP J.L1N�i>��Ll J4.iV.L7 J�.�'�®/'�^�� ,_ ♦ �.'asset�-� : � _ • -- �'aile�-�C � �e-xnspeei�ox��e�iuz'ec7(��'O.OU)�( � 2� 124 J/ fxtsneeforsyi aiuxe ozfials'} Slate �'asse$•, C } T+'aileti--r � � �e;�ns,�ecisox�xec�uixe� 050.00}-• [ � . ruq edorrs' comm eWS, ( ispeciozs', ignaictze-.aoInI iaTs) ))ate assecT--� � �'ailetT_(� �e�xnspee�Zo�a'es�uixe�(��O.UQ}Hj � . isp eciozs' comme�.is: C.inspBofors" pipaiuxe-Mfnifais) Pate ZiCAY,Gr-q D-WAgiONA:6 `R1I oectbxs9 eo�.e�tfis; W' 1 +: - (.Cts,�eetoxs'�zguaiuxe��io�n.z�axs) ' ;c ors' cols meds. . Date .. �lusp eeLoxs' �ignaiure � oto xivtia3s} . � date 3 'R 'TA Gk6 A*RV- , rVn *RW, Ti i7,T,T+',-D OT IT dM T R,,RT d"DMMA W TRF _AIRVA TO M INSPECTED Tq .NOT f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: c_-,,ejtJ_ &A & g�hone #: Are you mployer? Check the appropriate box: 1.am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).` have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. ' etm an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site nformation. nsurance Company Name: 'olicy # or Self -ins. Lic. #: Expiration Date: ob Site Address: City/State/Zip: Utach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ,ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine un4a $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of avestigations of the DIA for insurance coverage verification. r do hereby cert under the pains and penalties of perjury that the information provided above is true and correct. dgLaature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each �► year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1.877-MASSAFE Zevised 5 -26 -OS Fax # 617-727--7749 www,mass,gov/dia 9550 Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... . . .fCoh e . . has permission to perform ... ....... f �?a.................. plumbing in the buildings of .... 1.,: 7bW!. .................. at ... �O . & . k..P. ' ..S.% ....... .. , North Andover, Mass. Fee. No.. %OZL°G .14 ...... . PLUMBING INSPECTOR Check V e ' "SA,CHUSETTS U NORM APPLICATION FOR PERMIT TO 1) O PLUMJ3IlNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Building New Renovation Replacement 0 FIXTUR. ' •s J i it L■■.■�..-.� � is ��' ■■.■.=.... I (Print -or type) Installing Company Name Business Date/' Permitt #_— - Amount Chec one: ertificate Corp. �- Partner. Firm/Co. _ Name o£Licensed Plumber: Insurance Coverage: IndiV e of insurance coverage by checking appropriate box•.Bond Liability insurance policy Other type of indemnity. 11 ;Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature - - Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are.true and accurate to the best of mylmowledge and that all plumbing w rk installations performed andEKhaptci Issued for this application will be in complitance wish all pertinent provisions Oft;WCa sa hu A2 Plumug C f the General Laws. Type ofPlumbingLicense Title /I icense um er Master Journeyman - City/Town - APPROVED (oFFiCB USE ONLY - Location No. I / Date M°^Th TOWN OF NORTH ANDOVER .. o 9 F a w s Certificate of Occupancy $ sCNUS <� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # tJ Z 2 J O � 1 Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: / � Date Received Date Issued: ' RTANT: Applicant must complete all items on this LOCATION PROPERTY OWNER 106 Print MAP NO: _PARCEL: ZONING DISTRICT:, Historic District . yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other tWe l ��IFloodplain� IO�W,etlands= ®Watershed Dist. rict' 3 Septic k -;.-: L.'. .�.. _.3 �_ �..-..mss,•- ...�. ._w _..... ....._ _._ .._... __ -�_ _.,-. _�_. _ :_.— __ _. _,:� �.y�. .:3,.r�.t -'�- r#4�+1 ��t.._�. .-f. rt�x...-. DESCRIPTION OF WORK TO BE PERFORMED: e Identification Please Type or Print Clearly) Address: -`ZO.C- b04-kcr 5t - 9/Vzsc-!oV- CONTRACTOR Name: Jr Q Phone: Address: 1 � b/ L W C- ST /5�•�aZ * tt- Supervisor's Construction License: <oS�Z A -U Exp. Date: %/Z0AC// Home Improvement License:!�l5 �i Exp. Date: /Wzz r ZU%z ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST } / BASED ON $925.00 PER S.F. Total Project Cost: $ 76V FEE: $ Check No.: 1 16 2 Receipt No.: 3 { NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. (Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products JOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doe: Doc.Building Permit Revised 2008mi Plans Submitted ❑ - Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED FEI DATE APPROVED ❑N Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Comments Water & Sewer Connection/Signature & Daie Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA — For department use L1 Notified for pickup - Date Doc:.Building Permit Revised 2008 A.B. Custom Carpentry General Contractor ESTIMATE Contractor/Supervisor Lic. # 065280 Home Improvement Lic. # 145193 Fully Insured Date of Estimate: December 13, 2010 Client Name: Rick & Christy Catino Address: 205 Barker St. North Andover, MA. 01845 Phone: 978-258-1042 Joe Blanchet 124 Lake Street Haverhill, MA 01832 978-994-6134 Job Location: same Description of Work: Renovate basement approximately 26 ft. x 15 ft. Install 2x4's secured with screws on the flat to the concrete wall insulated with 1" Dow foam insulation board. Sheetrock walls and ceiling with blue board and skim coat fmish. Build a double closet at the bottom of stairs with a double pull raised panel door on each Frame closet in back right corner to cover water meter with door for entrance. Frame around boiler and water heat with a six foot double pull raised panel door Build wall for TV at angle in back left corner Build shelve on left of TV built-in Remove old window and re -Frame new window installation. Window will be vinyl new construction from Harvey industries. Redo wooden landing at bottom of stair and tile space 18 sqft Skim coat over rough texture in stairwell area. ' Install 2-8x6-8 hollow core raised panel door to unfinished room. Frame 2x4x4 wide partition approximately 6'-0"ft from corner Install tile 6x15 floor area at bottom of stairs. Bench seating with shelving above seat approximately 9'ft long and 18"inches out Paint walls and ceiling with primer Debris: A.B. Custom Carpentry will responsible for removal of all debris into rental dumpster. Permits: Permits needed for construction are: building t - DATE (MM/DDIYYYYI OF: L AB of/oa/toil ;CERTIPICATE. TI C TE I E MATTER: OF INFORMATION. ' vRooucER 603.382.4600 FAX 603.382.2034 E O LY 0 C FES RI �PI'ON.THE CERTIFICATE • OES NOT AM�Nb„ EXPEND OR,. Insurance 5o1 utions Corporation' L , C 0 BY TNE.POLICIES.8�L0)N 60 Westville Rd W.- WAS; : A.FP RMI 4{„+rl :'. •. :i?'� '� •. • , :•.ii .-. madAlMerGhantS IN Lt - .:. ... 23329 ,:: iNSuRED -y0se h Bl,anchet dba A B Cust0U1, Carpentry INSl1RERA:, • . i ..,..,...: •.. ,.. •. .. • • , . w...... , ........... . • lei4 lake:' St : :..... .:.... ....... •.. ... ..INSURER B: , ... Ffaver,',h-11; MA, 01832-1116 INSURER C: ,:.,. INSURER E;' COVERAGESkTED OF INSURANCE LISTED BELOW HAVE BEEN ISSUED RESPECTRED NAMED ABOVE OTO WHIICOH THIS CERTIFICATE MAY BE SUE OR (NG' . THE POLICIES OTHER DOCUMENT WITH DESCRIBED.HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR MAY PERTAIN; THE INSURANCE AFFORDED.BY THE POLICIES SHOWN MAY HAVE BEEN REDUCI=D BY PAID CLAIMS. POLICIES. AGGREGATE LIMITS uMrf9 LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD DATE MMID BOPI050253 07/07/2010 07/07/2011 EACH OCCURRENCE $ 1.000, OU GENERAL uA>311f(Y PREMIS 3 Es occurrence S SO-. Ov0 •' X COMMERCIAL GENERAL LIABILITY EXP (My one persgn) ; .. �S „OOO ...': CLAIMS MADE a OCCUR .MED PERSONAL 8 ADV INJURY A ' GEN ERALAGGREGATE $ 2 uVil iiDO $ 2 00 ,,00.- _ P PRODUC 73 C OM PLOP AGG , G)=N'L AGGREGATE LIMIT APPLIES PER ....: POLICY X <jEC LO•C BOPY050253 07/07/2010 07/07/Z011 COMBINED SINGLE LIMIT . $ AUTOMOBILE LIABILITY (Ea accidenf) 1-00... OO ANY AUTO BODILY INJURY $ ALL• OWNED AUTOS (P.et person) SCHEDULED AlJjOS A'.' BODILY INJURY . $ X` MIRED AUTOS (Pcrac4d'inf)' X NON OWNED AUTOS PROPERTY -DAMAGE $ ' (Pier accident) AUTO 'ONLY • EA ACCIDENT S EA ACO • $ -.OTHER THAN GARAGE L IA131LITY' ANY AUTO AUTO.ONLY: ., , AGG' S EACH OCCURRENCE $ EXCESS! UMBRELLA LIABILITY CLAIMS MADE OCCUR ED AGGREGATE $ $ 4' ' DEDUCTIBLE, $ RETENTION .$IATUIV"c WORKERS COMPENSATION YORY•LIMITS ER • 5 ELL EACHACCIDENT AND EMPLOYHRS'0AWLffY ANY FROPRIETOR/PARTNERIEXECUTIVE Y� O,FFICERlMEtdIBER EXCLUDED? EL DISEASE• EA EMP�,OY S. E.L. DISEASE P041CY LIMIT S (Mandatcry in NFY) : 1fVe., descnbo under SPECIAL PROVISIONS below OTHER DESCRIPTION OP OPERATIONS I LACAYYONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 9E CANCELLED BEFORE YHE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 OAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO YHE LEFT, BUT FAILURE TO DO SO SMALL TOwrl Of North Andover IMPOSE NO OBLIGATION OR LIABILITY OF ANY IOND UPON YHE INSURER ITS AGENTS OR Attn: Brian Leathe REPRES6NTATIM. 120 Main St AUTHOR°, EP111WENTA-11VE North,Andover, MA 01845 k_ / vlla-,L 0-#,.�-�-;- '978,:688: ®1988-2009 ACORD CORPORATION. All rights reserved. ACORD' 25' (2009101) FA}(� ' 9542 The ACORD name and logo are registered marks of ACORD 0 V' an E• z r cn n O cn C�n d 0 Z 0 m 0 U2 0 C CL cc 0 coc O C. 0 CL CA CO) m C', m a.& c Im °: my � =r CL L 0 m OCD CO) H 2 f m mCA CD W a 0 �o � o L H Ca ay :�CL ,..... O m CA a CA CA Lf1 CR : O.d Q W n CD ca ,0 �O m 0 ti CDm � 0,� am C � * C, c .� -ID Cc c?,0 co 0 = o x m �- 1 co 0 V' an E• z r cn n O cn C�n d 0 Z 0 m 0 U2 0 C CL cc 0 coc O C. 0 CL CA CO) m C', m a.& c Im °: my � =r CL L 0 m OCD CO) H 2 f m mCA CD W a 0 �o � o L H Ca ay :�CL ,..... 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J 0 The Commonwealth of Massachusetts Department of Intlustrial.Acciclents Office ofInvestigations 600 Washington Street Boston, MA 02111 U www mass.gov/clia 'W'orkers' Compensation Insurance Affidavit: Biiilders/ContraclorsfJElectrxcialas/Plumbers Applicant Information Please Print Legibly NaMO(B.usiness/Organization/lndividual): S& -I— AM -.13, CiPV-esy Address:-/ Z c( 4?4 r— City/State/Zip: Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I ewloyees (full and/or part-time).* have hired the sub -contractors 2. am a sole proprietor or partner- listed on the attached sheet. Y ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] f employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction. 7. ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11.0 Plumbing repairs or additions 12. F1 Roofrepairs 13. F1 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lie. #: Expiration Date: rob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,. as well as civil penalties in the form of STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby e ertify under the pains andpenaldes ofperjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # -Issuing Authority (circle one): 1. Board ofHealth 2. Building Department 3. City/Town CIerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Owner Responsibilities: to get tile and grout. Paint for wall and ceiling Additional Work: Any alteration or deviation from above specifications involving extras or vendor price increases will be discussed and will become an added charge over and above the estimate. Work performed at $55.00 per hour/per man Laborers will be $22.50 per hour/per man. Total Cost of Estimate: $11,900.00 Payment: A deposit is required before work can be started. Starting payment will be 1/2 of total and a last payment due after final inspection. Date /,2- Dat Dat/ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....................................................................... has permission to perform ...Am.4.,Ae.* ... ................................................... wiring in the building of .............. 0 ........................... .. ............. SJ . . )qqrth Andover, Mass. at... c . . ......... ................................... . Fee ... ELECTRICAL INSPECTOR Check it 9'1 42 A M (,ommonwea& o f )t'/addac4uaedJ 2,parimen% of Sire Serviced BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No: Occupancy and Fee Checked [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL YADP All work to be performed in accordance with the Nlassachusetts Electrical Code (MEC), 527 CNIR1? 00 (PLEASE PRINT IXNK OR TY EA INFORMATION) Date: — r City or Town of: To the Inspector of Wires: By this application the ur�dersigned lives notice of his or her intention to perform the electrical work described below. Location (Street &Number) 2o SiB f �� 1 ' Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Y No ❑ (Check Appropriate Bos) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: VA 0 VK) 0 vTtQ Fit r \ >n dl U 1-4S �}- V4 Dv �ed Si J Completion o the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) FansNo. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. arnd. o. o Emergency ig ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tonsl No. of Alerting Devices No. of Waste Dis osers p eat Pum Totals. t .umber -' Tons - - -- KW - o. of Self -Contained Det ction/Alerting Devices No, of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal Connection ❑ Other No. of Dryers Heating Appliances KW Seco. of Systems:* evi es or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover -is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE. BOND ❑ OTHER ❑ (Specify:) I certify, tinder thp�and peva ties of erjuty, that the information on this application is true and complete. c Cy FIRM NAME: �%� t lTin) LIC. NO.: J0 I Licensee:t v wQ Signatu a r�— �� LIC. NO.: ^7 (If applicabl , enter " empt" in the license number line.) Bus. Tel. No.: Cq -79 Address: IJt)0 IZ _,�e'WInS 0 ®� � Alt. Tel. No.: � 6LT *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner. ❑ owner's aent. Owner/Agent PERIYIIT FEE: Signature Telephone No. The Commonwealth of Massachusetts LX Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, A" -0211I www.mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: --A Am f tz- W O a b NO R. city/state/zip: 0"-i Phone #: 04, Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 1 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §.1(4), and we have no 1 insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction . 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. [1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other .-.uy -PP L-1, Wa: i,;UU:K:i U6w +'rf UF, also 1111 out the sec`Jon below showing their workers' compensation policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip:. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the �is andpenaMW ofperjury that the information provided above is true and correct 2p- t 3 Rg o 7 use only. Do not write in this area to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information and Instructions r � Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, of the . receiver or trustee of -an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apart rnents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ or Limited Liabili Partnershi s LP with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or 'license is being requested; not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. _. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/Iicense applications in any given year, need only submit one affidavit indicating current . policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or " town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth. of Massachusetts Department of Industrial Accidents. Office of Investiptiions 600 Washington. Street Boston, ASIA. 0.211.1 Tel # 617-727-4900 ext 406 or 1,877-M-ASWE Revised 5-26-05 Fax # 617-727-7749 v"rvm,.mass.govfdia 9373 13-11 Date..... . .. . .................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING n , 4 u This certifies that .................. i ............. ............. ........j .......................... has permission to perform ............. .:� . ............................. wiring in the building of .......... ............................................ at ...... ........... s ........ North Andover, Mass. LIc. No. IK ELECTRICAL INSPECWR Check,/ Commonwealth wealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT MINK OR TYPEALLXFOMW TION) Date: City or Town of: � To the Inspector of Wires: By this application the undersi ed gives no ' e of his or her intention to perform the electrical work described below. Location (Street & Number) C -7, Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / VoIts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. Yes Lv' No ❑ BLDG PERMIT # Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters +..u.,.tt—tttvrtut ue[ail TJ aesirea, or as required by the Inspector of fires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covern is in force, and has exhibited proof of same to the permit issuing office. CHECK ONELX: INSURANCE BOND 0 OTHER El (Specify:) I cert, under the pains and penalties of perjury, that the information on this application is true and cotraplet� FIRM NAME: 1 LIC. NO.: Q-� Licensee: Signa a LIC. NO.: (If applicable, enter "exempt" in the license number line.) �W:-:' Address: Bus. Tel. No.• *Per M.G.Lc. 47, s. 57-61, security work requires Department of Public Safety "S" icen �� LIC. NO.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL EUNDER GROUND INSPECTION: [ ] Failed — [ ] Re -inspection required ($50.00) -rs' comments: y i (Inspectors' Signature - no initials) Date 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: Passed — [ ] Failed — [ Inspectors' comments: - no NAME: uired ($50.00) - [ Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 0.2111 UV www.mas..gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/JElectricians/JPlumbelrs Applicant Information 1 I Please Print Leglibly Naiue(B.0siaess/Organization/individual): Address: 14 AAA6EakjoaA DR, TV/('50Nr tl City/State/Zip: 038 L k� Phone #: g 7 ._qq V Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ,gmployees (full and/or part-time).* have hired the sub -contractors 2. © I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing- repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Yam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: City/State/Zip; Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceYtify under the pains andpenalties ofperjury that the information provided above is true and correct. �M� Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. EIectricaI Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: // �f D IMPORTANT: Applicant must complete all items on this naize LOCATION fj rf-q— kms' ,5 4— Print PROPERTY OWNER C_4 ,g11rrr c 4L-4� C dil rt 3 Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes =Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ne family Addi 'on woor more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO E PERFORMED: V2 ��.- ays� �Q/7w . ! r / 1:7 Z, -4A4 e--;'— 7- OWNER: Na Address: CONTRACTOR Name: Please Type or �7? z9P1k1ayz Address: 17V Supervisor's Construction License: �' el -5- 2!fi-0 Exp. Date: /ZO/2D// Home Improvement License: / V, 5-/ Date: - ARCH ITECT/ENG I NEER ate: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: FEE: $ Check No.: 1�' Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne Signature of contract o sfa� Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract - ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy. Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008 zoLocation _ !��-�'f.�- _r7`7 No. Date - ,,ORTh TOWN OF NORTH ANDOVER 41 �a ; .` Certificate of Occupancy $ �ssCNUSE<�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # A 2LGJ Building Inspector E w w L V) o w z a c w 02 U w a w w u: a a w u: �j cn w o a c� w a] v) V) D J w O O F=4 C.LI 7O z E C o E m c o o C3 V C= d C O e0 ;= O � •,E z :v O E a dJ y O y C W cm m CD C m 0 cm c N CD Z 0 Z O O ZIO z O. E O Z co CL O y 0 C co cm h p 'C co LA O O E m m CD 0 co CL O G O L R O � CL �a Co .0" c O O .3 J •O C CD V y O C c ' c c H 0 uj 0 vI LLI N 19 W W U) H Os m J •_ m V la 'O N W ca m cm" C �: �• m O •v�Z Q • L � c� o m C y a i— y - y s = W CO �v = m 4:5 —0 W � m .. c 'd= O � h C N ca OF 012n wN ou � c� = O E a dJ y O y C W cm m CD C m 0 cm c N CD Z 0 Z O O ZIO z O. E O Z co CL O y 0 C co cm h p 'C co LA O O E m m CD 0 co CL O G O L R O � CL �a Co .0" c O O .3 J •O C CD V y O C c ' c c H 0 uj 0 vI LLI N 19 W W U) Circle Insurance Fax:978-777-d898 ALAIRD r CERTIFICATE OF LIABILITY INSUPANCE PRODUCER CERTIFICATE Circle Business Insurance Agency Inc 014LY AND CONFER 247 Newbury St. HOLDEIR. TM$ C C T ALTER ThEDanvers, ILII► 01923 978-777-7030 INSURERS AFFORD** INSURED Joseph Blanchat I =A 124 Take Street Haverhill, to 01832 INSURER C: INSURER D: _1978-994-6134 INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE; FOR THE POLI ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHI( MAY PERTAIN, THE INSURANCE APPORDED BY -THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM! POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. T. � ' R F URANCF POLICY NUMBER neltnuuFnnMn .,enY. D GENERAL LIABILm 0"ERCIAL GENERIJ A�-L- L�IWBILRY I CLAiMSMADE aOCCUR x GEN'L AGGREGATE LIMIT APPLIES PER: POLICY m- LOC AUTOMOBLLE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNEDAUTOS 4EXCGARAGE LIABILITY AW AUTO ESS/UMBMEL A LIABILITY OCCUR CLAIMSMADE DEDUCTIBLE- RETENTION EDUCTIBLERETENTION S WORKERS COMPENSATION AND EMPLOYERS LIABILITY B IAw--IETOWPARTNEWE) wT vF OFFMOWE"ER EkCLUOEDt I 680-9562N795 19/1/09 UB-5617CI90 (9/6/09 /VEHICLES/ 9/1/10 9/6/10 :11am P001/001 GATE WM/pDIYYYY OF INFORMATION THE CERTIFICATE IEND. EXTEND OR NAICS :Y PERIOD INDICATED. NOTWITHSTANDING N THIS CERTIFICATE MAY BE ISSUED OR EXCLUSIONS AND CONDITIONS OF SUCH LIMITS EACH OCCURRENCE $ 1.000.000 PREMISES As o=umnq S 1,000,000 MEDEXP(Anyawpmm) S 51000 PERSONAL &ADV INJURY S 1,000,000 GENERAL AGGREGATE 32,000,000 PRODUCTS-COMP/OPAGG s 2.000,000 COMBINED SINGLE LIMIT S (Eaae�oerll) BODILY INJURY = (PW parson) BODILY INJURY S (Peracdd" PROPERTY DAMAGE S (PareOgCarn) AUTO ONLY -EA ACCIDENT S OTHERTHAN EAACC S AUTOONLY: AGG $ EACH OCCURRENCE S AGGREGATE S s s X T" li LIMITS E.L,EACH ACCIDENT S 10O 0 o E.L. DISEASE • EA EMPL S 100 ,0001 EL,DISEASE.POLICYLIMTT S 500,000 I :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVI< DESCRIBED POLICIES BE CANCELLED BEFORE THE E)MIRATION 1600 Osgood Street North Andover DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 1600 Os North Andover, Mh 01845 NOTICE TO7RE CERTIFICATE MOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LUIBLLRY OF ANY KIND UPON THE INSURER ITS AGENTS OR Attn: Building In REPRESENTATIVES. g spector AUTHORIZED REPRESENTA Pax# 978-688=9542 DOI108) C ACORD CORPORATION 1989 auogd :uosaad ;asJu03 .Tag30 '9 .To;oadsul 2m mnid •S .To;oadsul j! v3.'ti VaI� un+o.L/14D '£ ivauu lndaQ fu!PI!ng 'Z giteaH;o p.Tsog •j :(auo ala q3) ,ijI.Toq;nV 2umssI 11�11/-Q�Z/W # asuaal�Twlad :UMOJL so 4i3 7ma�fo wool ao 4!3 dq pa;aldwoo aq o; Ivaav srq; ug a;iant;ou oQ •d'juo asn jv!mj o 700.uoa pun M4 q anogv pap:,toad uor;vu[.10fu1 3q; MW ALmlaad f'o saypuad pun suzvd ay; japun df' dga ray op I •uogsoguan a2ssanO0 aousmsaT .Toj yl(j;) p 3o suoTls2gsanul 3o aogiO aqP 01 pap TumToj aq SsuT laauralu;s su Ujo Moo z;egp pasrnps ag •iolujotn QtR }sure3B Xrp a 00.OSZ$ of dojo aug e Pue UR(I'd0 XUOM dO.LS E3o uuoj xg ut saglLmod I!Mo su Ilom su `juamaosuduq moA-ouo lo/puu 00'00S`i$ o; do aug ego saAleaad IeuTUTuojo uogisodun aq; of pool ueo ZSI •o -,E) I3o dSZ uOuoaS lapun paiTnbaT se Q21MOA00 amoas oq ampBd •(a sp uoi;B ndxa pus Taqumu iallod ag; 2uTuogs) a2sd uoi;sasiaap Sagod uogssuadwoa ,saa3laom aq; 3o ,fdoa s gas4d diZ/011PSP4!D :ssaippd a;iS qof :ajsQ uogv.i dxq :# •ojq 'su! 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pa;uosald uoaq anmq ia;dsgo sup jo swoumm►boi ooummsut aq; grim amtTetldutoo•jo oouopina ajgm;daoom IRun ij.Tom oijgndjo aoumuuojtad aug zoj;onwoo Sue o;ui ia;ua jlegs suoisinipgns jeogilod s;T3o Aum lou g;lmamuotuumo ag; lag;iarl„ sa;t.;s (L)0SZ§ `ZSI ioldsgo'IJY�I `�Itsuopippd « pamuba t agm tanoa ame.msut aq; qjV� aauttilduuoa;o aauapina alga;daoaE paanpo Td jou sug og u ;ucagddn ,Cue to; g;Imamuotuucoa ag; to s2tTippnq pmnsuoa olio ssauisnq u alundo o; jpa tad ao asuaail m;o lumaua.t .io aaumnssi aq; plogglpA jisgs Soua2m 2uisua3g Imaol so apps Irma„ ;ml; sa;u;s oslu (9)DSZ§ `ZSI za;dsgo IDW « ia�foldtua us Qq o; pauaaap oq;uaut ojduta gons•jo osnuooq;ou 1lsgs o;aiaul;;umounddu 2uiplinq jo sptmoif atl; uo so asnoq 2utllomp Bons uo:Iiom .nnda.t so uogon4suoo `ooueua;uieuT op o; suosiad sAoldmo ogm zaqjoun,jo asnoq guijjamp oT jo ;uudn000 ag; io `uTa.taq; sapisai oqm pure s;uouwede oomp a p asouu jou 2ujneg asnoq $uillamp u •jo numo atj; janamogsaaAojdtua ftjdojdtua `�gua je�aj iag;o so uoi;uioosse `digslau; and `junpinipui uu jo aa;sna jo lenuaoai mp so `saXoldtua posuaoop L, jo sanginuosasdai 10al a p ftpnjout puu `osudia;uo;u!of a m pafeguo fto2a.toj atl; jo a.Tom 10 om; Aus Io `A4guo ju3aj ntl;o 10 uoi;maodioo `uot;Etoossn `dulsiau;red `jenpinipui un„ sn pougop si aadfoldtua uv « ua um io jsio `poildua io ssa.zdxa iq jo;om.>;um Auu iopun ntl;ous•jo aointas aq; ui uosiod A.Tana•••„ ss pougop st aadojdwa um `a;n;u;s sig; o;;umnsmd •soo4oldmo nag; io3 uogssuadutoo sizjiom apino.Td o; smAolduma uls saunba.T ZSI ioldugo smut jniauoq s:4asngomssnyg suollan.11sul put, uoTJEiu.10jul fA AMLAL Q. �uftont C�rpeRtry General Contractor ESTIMATE Contractor/Supervisor Lie. # 065280 Home Improvement Lie. # 145193 Fully Insured 01832 Date of Estimate: November, 23 2009 Client Name: Richard &Christina Catino Address: 205 Barker St. North Andover MA. 01845 Phone: 978-258-1042 Joe Blanchet 124 Lake Street Haverhill, MA 978-994-6134 Job Location: same Description of Work: Install 2 windows on each side of the fire place on the first floor and re-sheetrock over existing ceiling. We will remove the sheetrock on each side of the fire place to frame both windows. Insulate as needed and re sheetrock over new framed windows. Sheetrock on ceiling and walls will be skim coat finish and then painted primer only. Windows will be trimmed out to match other windows in room. The outside of windows will be trimmed to match existing windows and siding will be re -used unless damaged by rot and that will be discussed with home owner if further action is needed and leads to additional cost. Windows: Owner supplied Painting: prime only Debris: A.B. Custom Carpentry will responsible for removal of all debris into rental dumpster. Permits: Building Permit supplied by contractor Owner Responsibilities: Additional Work: Any alteration or deviation from above specifications involving extras or vendor price increases will be discussed and will become an added charge over and above the estimate. Work performed at $55.00 per hour/per man Laborers will be $22.50 per hour/per man. Total Cost of Estimate: SV 6 0 -,0 Payment: A deposit is required before work can be started. Starting payment will be 1/3 of total and a 1/3 after framing inspection. Last payment due after final inspection. )��a (�,s ( ontr tors Signature omeowners Signature Date Date Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales t Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT �elei W,1"0 K CONSERVATION Reviewed on Signature COMMENTS HEALTH r� `--COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Locatea 364 usgooa Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA - (For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 Date.. !� --- '- 1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING *Ar.o This certifies that ..... ................... has permission to perform .... 17) T. ......................... plumbing in the buildings of ....(-..:-/! " :.4 ................... at.. ...... .. I North Andover, Mass. .00l - Fee ... b Lic. No.. 9'(,V.( . ....... AUM-BING INSPECTOR Check# J 5225 /v � Date .. �? ..... i TOWN OF NORTH ANDOVER .r* :-� PERMIT FOR GAS INSTALLATION This certifies that . .34....... /, ! `,e:......... ... . has permission for gas installation ...x!!. in the buildings of .�` r.�.!'. U ........................ . at..... .?().(;� .... Fee d S; 00. Lic. No.. �().. ..... GAS INSPECTOR Check # 6041 MASSACHUSETTS UNIFORM APPUCAT ON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations e"` Permit # Amount $ Owner's Name New 13 Renovation Replacement Plans Submitted (Print or type) Name /-J—1/,PiLlic, Address (-�) l?y y- 6" d `2- j "-?� 62 . , C,1Cf C) v Business 1 a ep one /'o X-71 /9 5, y Check one: Certificate Installing Company ElCorp. 0 Partner. 13-firm/Co. Name of Licensed Plumber or Gas Fitter(>�� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 2 No13 If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy 13/ Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent I hPrr.hx, rarhifi. +k. * nil —PA. e ,t..a..:1 ..aVF ,u,,,,,,,,vu kir emerea) in above appmatlon are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this ap lication will be in compliance with all pertinent provisions of the Massac tts ate G ode and apter 14 of the Gen l Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber C7� GasFitter=cense Mumoer 13 -Master Journeyman Ua v� Q Z Z O E� > a x a a w p x Z w > a y Q > w 0o a a Z a e d p z > SU B-BASEM ENT u x BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Name /-J—1/,PiLlic, Address (-�) l?y y- 6" d `2- j "-?� 62 . , C,1Cf C) v Business 1 a ep one /'o X-71 /9 5, y Check one: Certificate Installing Company ElCorp. 0 Partner. 13-firm/Co. Name of Licensed Plumber or Gas Fitter(>�� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 2 No13 If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy 13/ Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent I hPrr.hx, rarhifi. +k. * nil —PA. e ,t..a..:1 ..aVF ,u,,,,,,,,vu kir emerea) in above appmatlon are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this ap lication will be in compliance with all pertinent provisions of the Massac tts ate G ode and apter 14 of the Gen l Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber C7� GasFitter=cense Mumoer 13 -Master Journeyman MASSACHUSETTS UNIFORM APP'LlCATION FOR PERMIT TO DO PLUMBING fPrfnt or Type ,l � Mass. Date ` Permit #�.� �J Building Location ycY1'I',; Ir !� Owner's Name �G J;4 L2 y - Type of Occupancy'. New ❑ Renovation ❑ Replacement'Ll Plans Submitted: Yes ❑ No ❑ I_■ A b B.P.7 SEWERS FIXTURES SEPTIC# Name of Licensed Plumber J(-AP/yA-e— fffJ r/ Check one: ❑ Corporation ❑ Partnership ❑ Firmxo. Certificate r INSURANCE COVERAGE: ' I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YesX No ❑ If you have checked Les, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Anent Owner El Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installatio n"e permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State P:ig ZatoltC- and Chapfer 142 of the General laws. Title gY e City/Townn Type of License: Master Journeyman E]n� i APPfiOVED(OFFICE USE ONLY) License Number 7 O Gf 2 W (n X C 0. — < 0. — �. -4 U Z° m a s N d W } m < F < N= W— n < N z m a C O -j u [z �- y o= O L N P J Fes- < ie o LL Y cJ Y: v w m n a< 3 e m o O SUB—BS MT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR I STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR 1 Name of Licensed Plumber J(-AP/yA-e— fffJ r/ Check one: ❑ Corporation ❑ Partnership ❑ Firmxo. Certificate r INSURANCE COVERAGE: ' I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YesX No ❑ If you have checked Les, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Anent Owner El Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installatio n"e permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State P:ig ZatoltC- and Chapfer 142 of the General laws. Title gY e City/Townn Type of License: Master Journeyman E]n� i APPfiOVED(OFFICE USE ONLY) License Number 7 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTthr; (Print or Type) l NORTH ANDOVER Mass. tuilding Location___Q 0 A rIeC,"` Owners Name Date Permit # / ` • New . . Renovation �] Replacement Plans Submitted FIXTUR=c (Print or Type)eck one: Certificate Installing Company Name ��f �1!/y� jn Corp. Address d M Q - f_(SOe)/ S Partner. El�Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter �/i Insurance Coverage: Indicate + e type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. ignature of owner/agent of property Owner 17 Agent M 1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under' Permit issued for this application will -be In compliance with all pertinent Provisions of the Massachusetts State Gas Code and Chamer 142 of the General Laws. By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE: Plumber eo sfitter Signature o Licensed Master Plumber or Gasfitter Journeyman ���% �?' Li— cense Number . Y • ■■■■■■■■■■■■■ MIMESIS 0100110 1010■■n■■■■■■■■■■■■■■■■■■■■ .. 1010■■■■■■II■■■■■■■■■■■■S■■■■ .. .. - 1010■n■■■■■■■■■■■■■■■■■■■■■ .. - 1010■■■■■ ■ . ... 1010■■■■■■■■■■■■t■■■■■■■■■■t■■ (Print or Type)eck one: Certificate Installing Company Name ��f �1!/y� jn Corp. Address d M Q - f_(SOe)/ S Partner. El�Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter �/i Insurance Coverage: Indicate + e type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. ignature of owner/agent of property Owner 17 Agent M 1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under' Permit issued for this application will -be In compliance with all pertinent Provisions of the Massachusetts State Gas Code and Chamer 142 of the General Laws. By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE: Plumber eo sfitter Signature o Licensed Master Plumber or Gasfitter Journeyman ���% �?' Li— cense Number . Date.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that. ...... . .l has permission for gas installation ....%.� 1 - in the buildings of ....� �G' e-? a.. ! . !.�fr! ..: J.. . ....... . U y at ` (.." : ... .:.. J.. ...... , North Andover, Mass. Fee. .. r�Lic. No...—/. Air . ......................... . I` GASINSPECTOR ' f WHITE: AppllcanL,:.: CANARY: Building Dept. PINK: Treasurer GOLD: File 30331 Date ....... 71111.. `L TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .........:....:... /......................................................... has permission to perform e �'/ S wiring in the building of G C% J ��* ' N rth Andover, Mass. at...........................................�........................... Fee .... 5.... U... Lic. No. .............................?I ., ...�....... ELEMICAL INSPECTOR Check # 7) `// Commonwealth of Massachusetts official Use Only d Permit No. 3 731 Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 5 7 NyR 2.�Q (PLEASE PRINT ININK ORffedgives E LINFORMATION) Date: City or Town of: To the Inspector of fres: By this application the undersi no ' of his her inte i n to perform the electrical work described below. Location (Street & Nu er)20 , Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No L!r (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps i Volts Overhead ❑ Undgrd (J Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Installation of Securl No. of Meters No. of Meters Sys Completion of the following table may he waived by the Incnpctnr nfWirpr No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- rnd. rnd. ❑ IVO . omergencyrging Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat PumpNumber Totals: I Tons I KW I No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kit Security Systems: / No. of Devices or E uivalent ` No. of Water Kit HeatersSi No. of No. of ns Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value ofectrical Work:64?� (When required by municipal policy.) Work to Start: V 6c2'� Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: casLIC. NO.: 1530 Licensee: John S. Bassett Signature LIC. NO.: 1533C (If applicable, enter "exempt"in the license number line.) Bus. Tel. No.• 603 594 5928 Address Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Li , see does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $� Oz